Sunday, June 14, 2015

Shoulder Joint Replacement Arthroplasty - transexamic acid - topical vs IV? Will it work in the shoulder as well as in TKA and THA?

Topical Tranexamic Acid Was Noninferior to Intravenous Tranexamic Acid in Controlling Blood Loss During Total Knee Arthroplasty

These authors sought to determine how the safety and efficacy of topical tranexamic acid (TXA) compares with intravenous (IV) TXA. They conducted a blinded, controlled, randomized trial of  89 patients ≥18 years of age (mean age, 64.8 years; 74% women) who were undergoing elective unilateral primary total knee arthroplasty for osteoarthritis by an individual surgeon. 42 patients received topical and 47 IV TXA
42 patients were allocated to topical (2.0 g of TXA in 100 mL of normal saline solution directly into the surgical site, which was left undisturbed for 2 minutes before tourniquet release).  47 patients were allocated to IV TXA (a single 10-mg/kg dose of TXA 10 minutes before tourniquet release).

The topical and IV TXA groups did not differ in terms of the decrease in hemoglobin levels or  in terms of total drain outputs. 1 patient in the topical group required a blood transfusion. Postoperative complications included acute kidney injury (1 patient), myocardial infarction (1 patient), and death (1 patient) in the topical group and acute kidney injury (1 patient) in the IV group. There were no cases of deep-vein thrombosis or pulmonary embolism at 18.3 weeks postoperatively.

Comment: While  the current literature indicates that the use of TXA in total hip and knee arthroplasty is widespread, its use in shoulder arthroplasty is uncommonly reported.

Some papers at the AAOS did describe its use:

The Effectiveness of Tranexamic Acid in Reducing Blood Loss after Total Shoulder Arthroplasty
compared the effect of 100 cc of normal saline or 100 cc of normal saline with 2 g TXA by topical application into the wound at the completion of the case and found that the average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (p = 0.017). The average change in hemoglobin was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (p < 0.001).There were no transfusion requirements or postoperative complications noted in either group.

The authors of Tranexamic Acid Decreases Blood Loss Following Total Shoulder Arthroplasty used a dose of 20mg/kg IV given at the time of skin preparation. One-hundred-twenty-two consecutive patients were done between then and December 2012 and all received TXA and were included in this study (Group A). They were compared with the previous consecutive 108 patients done without TXA (Group B).

The mean dose was 1657 mg, resulting in a mean cost of $68. Statistically significant differences in both Hb loss (Group A change = 2.22 vs. Group B change 2.58, p=0.04) and Hct loss (Group A change = 6.67 vs. Group B change = 8.09, p < 0.01) were seen in the TXA group compared to the non TXA group. In patients receiving TXA, there were statistically significant decreases in the time spent in the recovery room (mean, Group A 68 mins vs. Group B 94 mins, p < 0.01) and total length of hospitalization (mean, Group A 1.16 days vs. Group B 1.36 days, p=0.03). Two patients in Group A received a blood transfusion while six patients in Group B received transfusions

A clinical trial Tranexamic Acid in Reverse Total Shoulder Arthroplasty (TXA) has been registered.

So it looks as though interest is rising in the use of this agent. Stay tuned.


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